Provider Location Information, which records information specific to each of a provider s active PQSR eligible practice locations.

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1 HMSA s for participating medical practitioners march 2010 Provider Validation Forms Each year, HMSA asks PQSR eligible practitioners to update their provider information to assist in prompt claims processing and payment. HMSA PQSR eligible providers have received computer printouts showing individualized information as it currently exists in HMSA files. Printouts are sent to providers who are active in PQSR at the time they are generated. The provider validation packet includes three types of printouts: Provider Basic Information, which records information common to all of a provider s practice locations. Provider Location Information, which records information specific to each of a provider s active PQSR eligible practice locations. HMSA Practitioner QSR Information, which records information related to the Practitioner Quality and Service Recognition (PQSR) Program and is provided to those practitioners who have at least one active non- PQSR group location. Practitioners that have all of their active PQSR eligible locations affiliated to a PQSR group will not receive this portion of the printout. The packet will include instructions for updating the information. If any of the information is different from that recorded on the printouts, providers are asked to note the corrections directly on the printouts and return them by the deadline indicated. What s Inside Page 2 New coverage codes, plan changes Page 3 Page 5 Billing and coding Medical policy changes Page 7 65C Plus Page 8 Tricare New HPV vaccine, Cervarix Human Papillomavirus bivalent (HPV Types 16 and 18) vaccine, trade name Cervarix, has been approved by the Advisory Committee on Immunization Practices (ACIP) and, HMSA s private business plans covers this vaccination for dates of service beginning with October 21, 2009, and after. Cervarix is covered when administered to females ages 9 through 26, and coverage is limited to three doses per lifetime. Providers should bill with CPT code 90650, for the vaccine material, and the appropriate CPT vaccine administration code as listed in the E-Library, Immunization Administration document. The Maximum Allowable Charge (MAC) for the vaccine material is $ Gardasil Update Also on October 21, 2009, ACIP approved the HPV quadrivalent vaccine, Gardasil, to immunize males ages 9 through 26. HMSA s private business plans cover Gardasil for males, for dates of service beginning with October 21 and after. Coverage is also limited to three doses per lifetime, per member. PS Hawaii Medical Service Association 818 Keeaumoku St. P.O. Box 860 Honolulu, HI Phone: (808) Branch offi ces located on Hawaii, Kauai and Maui Internet address: Provider Resource Center: hhin.hmsa.com

2 2 Provider Update - Medical Practitioners March 2010 Plans Updates New coverage code 577 Effective January 1, 2010, American Savings Bank employees are eligible for a new Preferred Provider Plan (PPP), coverage code 577. This plan features a physical examination benefit that is covered at 100 percent of eligible charge (EC) and is not subject to the plan s annual deductible. To receive coverage, the service must be performed by an HMSA participating provider. Physical examinations are limited to one per calendar year and include routine vision and hearing tests, and recommended screening tests based on age and gender, as follows: Recommended examinations for ages 6 through 12: Complete school examination form 414 Additionally, for ages 13 and above: Complete history and physical examination Audiogram (optional) Urinalysis Blood count Chest X-ray (optional - not more than once every two years) Also for ages 40 and above: Biochemistry panel Electrocardiogram (EKG) Please review the details of coverage code 577 through HMSA s HHIN. Screening colonoscopy for PPO plans Effective January 1, 2010, the majority of HMSA s PPO and CompMED plans include coverage for screening colonoscopy services. Routine colonoscopy screening is covered when performed for PPO and CompMED members age 50 and older and is limited to one screening every ten years. Plans that do not include screening. The following HMSA PPO coverage codes do not include coverage for screening colonoscopy: 455, 532, 533, 562, 563, 667, 621, 644. Annual Copayment Maximums and Annual Deductibles Changes for Foodland To review criteria and limitations, please review medical policy, Screening Colonoscopy - Effective January 1, 2010, in the Provider E-Library. Verify coverage by looking up PPO and CompMED plans by coverage Effective January, 1, 2010, coverage codes 613, 614 and 615 have increased all or some of their annual copayment maximums and annual deductibles. Here is a list of maximums and deductibles, in effect beginning January 1. Annual Copayment Maximum (per calendar year) Annual Deductible (per calendar year) Coverage Code 613 Coverage Code 614 Coverage Code 615 $1,500 per person (includes $1,000 per person/$3,000 $1,500 per person/$4,500 annual deductible) per family (includes annual per family (includes annual deductible) deductible) $100 per person (applies toward annual copayment maximum) $100 per person/$300 per family (applies toward annual copayment maximum) $150 per person/$450 per family (applies toward annual copayment maximum) For more details, please look up each coverage code on HHIN.

3 3 Provider Update - Medical Practitioners March 2010 Modifications to X-N Effective January 1, 2010, existing coverage code X-N has been modified with the following changes. The annual copayment maximum is $2,500 per person/ $7,500 per family Physical exams, well-child, and well-woman exams are covered at 100% of eligible charge (EC) Immunizations for members ages 19 and older are covered at 100% EC Member copayment for hospital room and board is $75 per day Member copayment for emergency room is $75 Blood and blood products are covered at 100% EC Dialysis (hospital outpatient setting) are covered at 90% EC Medical equipment, appliances and supplies (internal items) are covered at 100% EC Pleaser review more details of this plan by looking by the coverage code on HHIN. Billing and Coding J-codes updated on HHIN MAC fee information on J-code injectables, available online via HHIN, has been updated with the 2010 fees. So You Don t Have Access to HHIN?! Register with Traci Tabladillo, HMSA s Provider ecommerce at 1 (808) or toll free 1 (800) ext from the Neighbor Islands, or Traci at: traci_tabladilo@hmsa.com. Billing Avastin for macular degeneration treatment HCPCS code Q2024, recently implemented to give physicians a way to bill for off-label use for treatment of ophthalmologic indications with bevacizumab (Avastin), has been discontinued. Since there is no replacement code, physicians must bill HCPCS code J3590, unclassified biologics, and include in box 19, intraocular Avastin and the total dosage, for CMS 1500 claims. Claims submitted with the incorrect code will be denied and returned for code correction. A section in the HMSA s medical policy, Bevacizumab (Avastin), located in the Provider E-Library, covers off-label use and includes a list of ophthamologic indications providers should review prior to billing ICD-9-CM diagnosis(es). H1N1 billing reminder: Multiple vaccine administrations on the same day When H1N1 is administered with any other immunization on the same day, bill one line for the H1N1 administration and bill the appropriate additional vaccine administration code on a separate line. Proper use of Modifer 25 Modifier 25 is used to report a significant, separately identifiable Evaluation & Management (E/M) service by the same physician on the same day of a procedure or other service. This modifier is used to document instances where the patient s condition required an E/M service above and beyond the usual care associated with the procedure or other service. (continue on page 8)

4 4 Provider Update - Medical Practitioners March 2010 Paper Claim Submitters, Be Aware! Follow best practices when printing claims Claims that do not follow the criteria listed below, shall be returned to the provider for correction and resubmission. CMS 1500 forms submitted on paper, must be: The latest version of the CMS 1500 claim form, CMS 1500 (08-05) Printed with the special red fade-away ink which allows claims to be electronically read by OCR equipment. (See CMS 1500 CLAIM FORM - VENDORS in the Provider E-Library for a list of vendors.) Review your print protocol and follow these tips for cleaner print production: Use Arial or Times New Roman fonts Use font sizes 10 through 12. Font sizes below 10 are not clear, and font sizes above 12 don t fit in the blocks. Avoid using dot-matrix printers and change printer ribbon frequently. It is difficult for the scanner to pick up dot-matrix print clearly. Strive for print output of high quality, with characters appearing sharp and clear. Use single line text for each block. The OCR scanner is unable to read two lines squeezed into a block. Keeping font sizes at 10 or 12 will discourage this practice. Do not print claims information with red ink. Claim forms that are printed with the fade away red ink allows scanners to pick up only claims information printed in black ink. Printing information in red ink will result in scanning a blank page. Do not highlight anything! Scanner will be unable to read and pick up the information in the area highlighted. Need HHIN? Contact Traci Tabladillo, HMSA s Provider ecommerce at 1 (808) or toll free 1 (800) ext from the Neighbor Islands, or Traci at: traci_tabladilo@hmsa.com. Check your claims for completion errors: Place of Service (POS), box 24b. Enter the complete twodigit code. Modifiers, box 24d. Enter the two-digit modifier number only. NO NOTES! Service line, boxes 24 a-j. List complete information. No ditto marks, lines, same, same as above, or any indication that would require HMSA s claims reviewer to check in another area of the claim for information that should be on that service line. Multiple page claims The total charge should be entered on the last page as the sum of all charges. See MULTI-PAGE CLAIMS in the Provider E-Library. We will not accept: Faxed claims Paper claims submitted on copier-printed CMS 1500 forms

5 5 Provider Update - Medical Practitioners March 2010 Policy News Codes that do not meet Payment Determination Criteria The following code has been removed from the codes that do not met payment determination criteria list. HCPCS code E0472 Annual review of medical policies The following policies have undergone annual review and have been updated: Blepharoplasty and Repair of Blepharoptosis Computerized Corneal Topography Lung Volume Reduction Surgery Off-label Uses for Drugs and Biologicals in an Anti-Cancer Regimen Panniculectomy/Abdominoplasty Reduction Mammaplasty Treatment of Varicose Veins Please refer to the Provider E-Library to view the individual policies. Copies of the policies are available upon request. Provider input solicited for annual policy review March HMSA s medical directors welcome comments and suggestions from participating physicians regarding existing medical policies that are undergoing annual review. Following is a list of policies for which HMSA is currently soliciting input. Comments are due by March 31, Physicians may comment by fax at (Oahu) or via to medical_policy@hmsa.com. Comments will be taken into consideration during the annual review process. However, HMSA does not guarantee any specific proposed change will be included in the final policy. HMSA s policies rely on the use of evidence-based medicine, typically from peer-reviewed literature. Physicians submitting comment should include supportive citation source material to assist HMSA s medical directors in evaluating the comment or proposed change. Erythropoiesis Stimulating Agents (ESA) Extracorporeal Membrane Oxygenation (ECMO) for Neonates FDA Approved Drugs Requiring Precertification Fentanyl Oral Products Fentanyl Transdermal System (Duragesic) Infliximab (Remicade) In Vitro Fertilization Medical Foods for Inborn Errors of Metabolism Pulmonary Arterial Hypertension Drugs Radiofrequency Catheter Ablation of the Pulmonary Veins as Treatment for Atrial Fibrillation Thoracic Sympathectomy for Hyperhidrosis Vacuum-Assisted Breast Biopsy

6 6 Provider Update - Medical Practitioners March 2010 HMSA Benefit for Physical and Occupational Therapy The physical and occupational therapy benefits described here apply to HMSA s private business plans, including HSTA and EUTF plans, Federal plan 87 and QUEST. HMSA covers physical and occupational therapy on a short term basis when ordered by a physician, physician s assistant or advanced practice nurse practitioner (as allowed by law) under an individual treatment plan. Services must be provided by a qualified therapist or rendering provider and necessary to achieve a specific diagnosis-related goal that will significantly improve neurological and/or musculoskeletal function that was lost or impaired due to illness, injury, or prior therapeutic intervention. Short-term therapy is defined as services necessary to improve or restore functions required to perform normal activities of daily living and generally lasts no longer than three months. Therapy beyond this is considered long-term and not covered. Maintenance therapy, defined as activities that preserve present functional level and prevent regression, is also not covered. HMSA has developed specific policies to address physical and occupational therapy. These medical policies, which describe criteria for coverage as well as limitations and exclusions, can be found on HMSA s Provider E-Library. Landmark Healthcare Inc. Due to increasing utilization of therapy services and resulting costs, HMSA has contracted with Landmark Healthcare Inc. (Landmark) to assist in the management of outpatient physical and occupational therapy services. The goal of this management program is to ensure that HMSA members receive high quality, patient-focused care that is tailored to their response to treatment and maximizes use of their plan s benefits. precertification for visits beyond eight visits for PPO, HMO and QUEST members. For Fed 87 members, precertification is required after 10 visits. Precertification requires the submission of a treatment plan to Landmark. Beginning January 1, 2011, Physical therapists will be placed in one of three tiers based on their utilization patterns. The placement in a tier determines what, if any, precertification requirements apply. Occupational therapists will continue to require precertification after the applicable eight or 10 visits Role of Referring Physician Physicians often refer patients for physical therapy with different instructions to the therapist or rendering provider. Some physicians ask the rendering providers to follow a predetermined protocol, especially postoperatively. Others refer patients with orders to evaluate and treat. With precertification required after the first eight or 10 visits, HMSA views this as an opportunity for referring physicians and therapists and other rendering providers to work more collaboratively in the care of the patient to provide appropriate therapy for the patient s condition with both one-to-one sessions with the therapist and initiation of a home exercise program at the inception of therapy. Members who are currently receiving physical and occupational therapy services were notified about these new requirements. In addition, members who received more than 24 visits in 2009 were also made aware of this new program. Landmark s program will be implemented as follows: From April 1, 2010 December 31, 2010: Physical and occupational therapists, will be required to obtain

7 7 Provider Update - Medical Practitioners March C Plus Do not file claims using consultation codes Effective January 1, 2010, consultation CPT codes (ranges and ), are no longer recognized by Medicare Part B. Practitioners who perform consultations, whether inpatient or outpatient, must not submit claims billed with the above-mentioned consultation codes to HMSA s 65C Plus or Medicare. This change applies to dates of service on and after January 1, Claims received with the incorrect consultation codes will be returned, with a message asking provider to use another code for the service. Practitioners should use the appropriate initial Evaluation & Management (E/M) code for the service that best reflects the complexity level performed. Centers for Medicare & Medicaid Services (CMS) provide detailed billing instructions and examples on how to bill for patient care provided by multiple physicians. Please refer to the MLN Matters Number: MM6740 Revisions to Consultation Services Payment Policy on the CMS MLN Matters website at MLNMattersArticles/. Here is one example from the MLN Matters policy: When physician orders observation services and furnishes the initial evaluation, he or she may bill the initial observation care code. Another physician who is called in to evaluate the patient must bill the appropriate new or established E/M code for his or her services. billing an E/M code, the principal physician of record should append modifier AI, Principal Physician of Record. This will identify the physician as overseeing the patient s care from those physicians who may be furnishing specialty care. Coordinating claims with dual coverage When an HMSA private business plan is the primary coverage and Medicare (including HMSA s 65C Plus plans) is secondary, providers must bill the consultation code when filing with HMSA, and file the appropriate E/M code when submitting to HMSA s 65C Plus or to Medicare. Please note that HMSA s primary private business claims may automatically process under the secondary HMSA 65C Plus, resulting in a denial of the consultation code. To receive secondary payment under 65C Plus, the claim must be corrected and resubmitted. Submit a claim with the appropriate E/M and attach the HMSA RTP reflecting the primary payment of the consultation code. The HMSA s 65C Plus member number must be indicated in Block 1a of the resubmitted CMS 1500 claim. Practitioners must familiarize themselves with the new Medicare policy and adjust their billing processes accordingly. Also explained in the MLN Matters policy is how to bill when the physician is the physician of record. When See MLN Matters Number: MM6740 Revisions to Consultation Services Payment Policy on the CMS website at:

8 8 Provider Update - Medical Practitioners March 2010 Proper Use of Modifier 25 (continued from page 3) Modifier 25 should not be billed: With E/M codes that are explicitly for new patient visits. When only laboratory procedures were performed. With E/M codes for preventive medicine, unless an illness or abnormality was encountered and addressed. procedure or other service. Medical record documentation must support the use of this modifier. As a reminder, retrospective reviews may be conducted as part of HMSA s Utilization Management Program to monitor appropriate coding and use of modifier 25. On the same day as a pre-scheduled or planned TRICARE Important Notice Regarding Timely Claim Filing for Network and Non-Network Providers TRICARE requires that all claims must be received by the TRICARE West Region claims processor, Wisconsin Physicians Services (WPS), within timely filing requirements. Claims must be submitted: Within one year from the date the services were provided. Inpatient facility charges must be received within one year from the date of discharge. Professional services billed by the facility must be received within one year from the date the services were rendered. Please submit any outstanding TRICARE claims prior to the one-year deadline. Claims will only be processed according to the timely filing guidelines as defined by the TRICARE Operations Manual, Chapter 8, Section 3. For more information, please refer to the TRICARE Operations Manual at: mil/.